Title | 1 | The words ‘case report’ (or ‘case study’) should appear in the title along with phenomenon of greatest interest (eg, symptom, diagnosis, test, intervention) |
Keywords | 2 | The key elements of this case in 2–5 words |
Abstract | 3 |
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a) Introduction—What does this case add? -
b) Case Presentation:
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– The main symptoms of the patient -
– The main clinical findings -
– The main diagnoses and interventions -
– The main outcomes
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c) Conclusion—What were the main ‘take-away’ lessons from this case?
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Introduction | 4 | Brief background summary of this case referencing the relevant medical literature |
Patient information | 5 |
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a) Demographic information (eg, age, gender, ethnicity, occupation) -
b) Main symptoms of the patient (his or her chief symptoms) -
c) Medical, family, and psychosocial history—including diet, lifestyle, and genetic information whenever possible, and details about relevant comorbidities including past interventions and their outcomes
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Clinical findings | 6 | Describe the relevant physical examination (PE) findings |
Timeline | 7 | Depict important dates and times in this case (table or figure). |
Diagnostic assessment | 8 |
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a) Diagnostic methods (eg, PE, laboratory testing, imaging, questionnaires) -
b) Diagnostic challenges (eg, financial, language/cultural) -
c) Diagnostic reasoning including other diagnoses considered -
d) Prognostic characteristics (eg, staging) where applicable
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Therapeutic intervention | 9 |
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a) Types of intervention (eg, pharmacologic, surgical, preventive, self-care)
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– Administration of intervention (eg, dosage, strength, duration) -
– Changes in intervention (with rationale)
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Follow-up and outcomes | 10 |
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Discussion | 11 |
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a) The strengths and limitations of the management of this case -
b) The relevant medical literature -
c) The rationale for conclusions (including assessments of cause and effect) -
d) The main ‘take-away’ lessons of this case report
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Patient perspective | 12 | The patient should share his or her perspective or experience whenever possible |
Informed consent | 13 | Did the patient give informed consent? Please provide if requested |